Discussion of public health and health care policy, from a public health perspective. The U.S. spends more on medical services than any other country, but we get less for it. Major reasons include lack of universal access, unequal treatment, and underinvestment in public health and social welfare. We will critically examine the economics, politics and sociology of health and illness in the U.S. and the world.

Thursday, July 12, 2007

Doctor Chatterbox

You've likely heard about the study by Susan McDaniel and colleagues (abstract only for the underprivileged) which finds that doctors often talk about themselves when, in the authors' view, they should be worrying about their patients instead. I have reservations about this paper -- they present a few examples that look anywhere from mildly to highly inappropriate -- but they don't have any actual evidence that these behaviors are necessarily harmful, or that they represent a big problem. I would call that a hypothesis raised by these observations, not a finding as they would like to have it.

I must say as well that, although I haven't been systematically looking for this particular category of behavior, I'm pretty sure I don't see as much of it in the hundreds of medical visits I have studied as they do. Most of the shootin' the shit kinds of interactions, talk that's unrelated to the business of the medical visit, seems to be entirely consensual and is often initiated by the patients. An important difference, however, is that McDaniel et al's data consists entirely of first meetings between M.D. and patient, whereas mine is generally of ongoing relationships. Physician self-disclosure seems less jarring and more appropriate when the parties know each other and have formed a bond.

All that said, it's still somewhat ironic and does highlight the converse problem in physician-patient interaction, which is that physicians are not generally very amenable to patient disclosures which stray too far from the strictly biomedical. Where it's known to be an issue, physicians will often ask about specific contextual problems such as criminal justice involvement, illicit drug use, housing, etc. But they generally have little understanding about patients' life worlds and neither know nor seem to care about how the problems of daily living may affect their ability to follow medical advice, take their pills, eat the proper diet, exercise, etc. When people complain of depressive symptoms, they'll get a prescription, rather than any effort to understand why they might feel sad. Now, an internist is not a psychotherapist, but doctors can certainly do a much better job of listening, and encouraging patients to confide in them. I'm not so much worried about doctors talking about themselves, as I am about them not letting patients do the same.